DAP HealthNon-Profit

Department of Health and Human Services Federal Financial Assistance Listing #93.224 and #93.527 Health Centers Program Cluster pecial Tests and Provisions Material Weakness in Internal Control over Compliance and Noncompliance Criteria: Health centers must prepare and apply a sliding fee discount schedule (sliding fee discounts) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The sliding fee discount is based on an individual’s or family’s income in relation to the Federal Poverty Guideline (FPG). In order to support a patient’s eligibility to receive a sliding fee discount, the health center is required to obtain certain documentation from the patient and/or family to support the patient’s or family's income in relation to the FPG. Condition: The Organization failed to obtain the required income verification from 19 patients; however, these patients were given the sliding fee discount. Cause: Internal controls in place did not ensure that the sliding fee discount was not given until all income verification was obtained. Or, in cases where the sliding fee discount was granted pending income verification, the income verification was not completed resulting in a sliding fee discount being given without adequate support. Effect: The lack of adequate policies governing obtaining the income verification documentation resulted in a sliding fee discount being given without proper support. In addition, there was not adequate follow up to ensure the income verification was completed for those individuals given the sliding fee discount pending income verification. Questioned Costs: $2,075. Context: A sample size of 60 with a total sample amount of $10,488 was tested. The number of patients who received the sliding fee was 11,426 with a total value of $1,462,691. Of the 60 tested, 19 selections, which totaled $2,075, were given the sliding fee discount when the appropriate eligibility documentation was not obtained. Repeat Finding from Prior Year: Yes, Finding 2024-004 Recommendation: We recommend that the Organization enhance control policies to obtain the required income verification at the time the sliding fee discounts is granted and to enhance the internal control policies regarding follow up with patients for missing or incomplete income verifications. Views of Responsible Officials: Management agrees with the finding. In May 2025, the Organization completed additional training and provided education for staff to explain why the sliding fee discounts cannot be given until a completed file, including income verification support, is obtained. Management has implemented ongoing internal reviews, monthly reporting and ongoing training. Workflows with the electronic medical record systems have been reviewed and revised to assist in monitoring the sliding fee applications and awards. Desk Procedures were prepared and are being implemented as additional training tools to ensure new staff follow policy and procedures.

Department of Health and Human Services Federal Financial Assistance Listing #93.224 and #93.527 Health Centers Program Cluster Reporting Significant Deficiency in Internal Control over Compliance and Noncompliance Criteria: Health Center Program awardees and look-alikes are required to report a core set of information, including data on patient characteristics, services provided, clinical processes and health outcomes, patients’ use of services, staffing, costs, and revenues as a part of a standardized reporting system known as the Universal Data System (UDS). There are very specific criteria on how the UDS Report is to be completed contained in the UDS Manual published by the Health Resources and Services Administration. The information needs to be reported annually on a calendar year basis regardless of a grantee’s fiscal year-end. Condition:One table within the UDS Report did not reconcile to the information contained in the Organization’s records. That table that did not reconcile to the supporting information was Table 5, Staffing and Utilization. Table 5 reports the number of clinics by both physicians and Nurse Practitioners (NP), Physician Assistants (PA), and Certified Nurse Midwives (CNM). The number of clinic visits by physicians reported in the UDS report was 102,194 (clinic and virtual) while the number of clinic visits noted in the supporting documentation was 103,026 (clinic and virtual). The number of clinic visits by NPs, PAs, and CNMs reported in the UDS report was 76,095 (clinic and virtual) which agreed with the supporting documentation. Cause:Internal controls in place did not ensure that the number of clinic visits reported in the UDS report agreed to the supporting documentation. Effect:The Organization submitted a UDS Report that did not have supporting documentation that reconciled to the amount reported for physician clinic visits. Questioned Costs:None reported. Context:Seven key line items on the UDS Report are required to be reconciled to supporting documentation. 1. The total number of patients 2. Total Physician Clinic and Virtual Visits 3. Total NP, PA, and CNM Clinic and Virtual Visits 4. Total accrued costs before donations and after allocation of overhead. 5. Total accrued medical staff and other medical costs after allocation of overhead excluding lab and x-ray costs. 6. Total BPHC Health Center Program grants drawn down for the period from January 1 to December 31, of the calendar measurement year. 7. Total accrued PBHC COVID-19 Supplemental grants drawn-down from January 1 to December 31, of the calendar measurement year. One key line item (#2 above) did not agree to the supporting documentation. Repeat Finding From Prior Year:Yes, Finding 2024-003 Recommendation:We recommend that the Organization enhance control policies to ensure all amounts reported and submitted to the federal agency are adequately documented and supported. We also recommend that the Organization enhance internal control policies to ensure that all required reports are properly reviewed prior to submission and that all key line items are necessary, correct, meet the requirements of the federal program, and are properly reported in the reports required to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding. The Organization has successfully implemented a robust, auditable, and reproducible framework for UDS reporting, ensuring long-term data integrity and accessibility. The 2024 UDS data gap discovered during the 2025 audit resulted from a correction of data filed where the HRSA UDS report was changed but the supporting documentation was not corrected to reflect the change in visits. We have corrected this for the 2025 UDS report and have already validated the supporting documentation and the UDS Report reconcile.

Department of Housing and Urban Development Federal Financial Assistance Listing #14.241 Housing Opportunities for Persons with AIDS (HOPWA) Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Criteria Grantees receiving funding through the HOPWA program must complete and submit the HUD-4155 Consolidated Annual Performance Report (APR) and Consolidated Annual Performance and Evaluation Report (CAPER) (Consolidated APR/CAPER) no later than 90 days after the close of their program or operating year. The Consolidate APR/CAPER provides information on program accomplishments that supports program evaluation and the ability to measure program beneficiary outcomes as related to maintaining housing stability, preventing homelessness, and improving access to care and support. Condition Certain information related to Short-Term Rent, Mortgage and Utility (STRMU) expenditures and Permanent Housing Placement (PHP) expenditures did not reconcile between the Consolidated APR/CAPER and the general ledger. In addition, the Consolidated APR/CAPER was not reviewed by someone other than the preparer prior to submission. Cause Internal controls in place did not ensure that the monthly expenditure information that was summarized and used to prepare the Consolidated APR/CAPER was reconciled to the general ledger. The monthly expenditure information did not take into account any reconciling or other entries recorded after the monthly information was generated which led to differences between the expenditures report in the Consolidated APR/CAPER and the actual STRMU and PHP expenditures as reflected in the general ledger. Internal controls were also not in place to ensure review of the supporting documentation and the Consolidated APR/CAPER prior to submission. Effect The lack of a reconciliation process from the expenditure information reported in the Consolidated APR/CAPER to the general ledger increases the risk that information contained in the Consolidated APR/CAPER and reported to the Department of Housing and Urban Development will contain errors that are not detected and corrected by employees. The Organization submitted a Consolidated APR/CAPER with incorrect information. Questioned Costs None reported. Context The STRMU expenditures and the PHP expenditures were both tested and both amounts reported in the Consolidated APR/CAPER did not agree to the general ledger. Repeat Finding From Prior Years No Recommendation We recommend that the Organization enhance internal control policies to ensure all amounts reported and submitted to federal agencies ar adequately documented and supported. We also recommend that the Organization enhance internal control policies to ensure that any required reports are properly reviewed prior to submission to ensure all key line items are correct and supported. This review should be documented. Views of Responsible Officials Management agrees with the finding and has immediately initiated corrected reports with the grantor and implemented extra procedures to review program required reporting between Program and Finance Leadership prior to submission.

Department of Health and Human Services Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting Material Weakness in Internal Control Over Compliance Criteria Health Center Program awardees and look-alies are required to report a core set of information, including data on patient characteristics, services provided, clinical processes and health outcomes, patients’ use of services, staffing, costs, and revenues as a part of a standardized reporting system known as the Universal Data System (UDS). There is very specific criteria on how the UDS is to be completed contained in the UDS Manual published by the Health Resources and Services Administration. The information needs to be reported annually on a calendar year basis regardless of a grantees’ fiscal year-end. Condition Certain tables within the UDS Report did not reconcile to the information contained in the Organization’s records. The tables that did not reconcile to the supporting information included Table 4, Selected Patient Characteristics, and Table 5, Staffing and Utilization. Table 4 reports the total number of patients. The number of patients reported in the UDS Report was 74,680 while the number of patients noted in the supporting documentation was 73,021. Table 5 reports the number of clinic visits by both physicians and by Nurse Practitioners (NP), Physician Assistants (PA), and Certified Nurse Midwives (CNM). The number of clinic visits by physicians reported in the UDS Report was 102,677 (clinic and virtual) while the number of clinic visits by physicians noted in the supporting documentation was 115,177 (clinic and virtual). The number of clinic visits by NPs, PAs, and CNMs reported in the UDS Report was 62,915 (clinic and virtual) while the number of clinic visits by NPs, PAs and CNMs noted in the supporting documentation was 82,621 (clinic and virtual). Cause The Organization acquired Borrego Health on July 31, 2023. Borrego Health used a different medical record system than the Organization through late May 2024. This resulted in the UDS Report for the period ended December 31, 2023 needing to be prepared using two different databases for information. In addition, management did not retain the supporting detail used to prepare the UDS Report. When the supporting detail was recreated during the audit, differences were identified between the supporting detail and the UDS Report that was filed. Also, the review process of the UDS report does not appear to have been functioning properly. Effect The lack of internal control policies to require retention of supporting documentation as well as a lack of evidence of a review outside of the person preparing the report increases the risk that employees may not be able to detect and correct errors and issues in a timely manner. The Organization submitted a UDS Report that did not have supporting information and the information that was recreated does not reconcile to the amount shown in the UDS Report filed. Questioned Costs None reported. Context Seven key line items on the UDS Report are required to be reconciled to supporting documentation: 1. The total number of patients 2. Total Physician Clinic and Virtual Visits 3. Total NP, PA, and CNM Clinic and Virtual Visits 4. Total accrued costs before donations and after allocation of overhead 5. Total accrued medical staff and other medical costs after allocation of overhead excluding lab and x-ray costs 6. Total BPHC Health Center Program grants drawn down for the period from January 1 through December 31 of the calendar measurement year 7. Total accrued BPHC COVID-19 Supplemental grants drawn down for the period from January 1 through December 31 of the calendar measurement year. Two of the key line items (#1 and #2 above) did not agree to the supporting documentation. Repeat Finding From Prior Year No Recommendation We recommend that the Organization enhance internal control policies to ensure all amounts reported and submitted to the federal agency are adequately documented and supported. We also recommend that the Organization enhance internal control policies to ensure that all required reports are properly reviewed prior to submission and that all key line items are necessary, correct, meet the requirements of the federal program, and are properly reported in the reports required to be submitted to the federal agency. We also recommend that there is evidence retained of this review. Views of Responsible Officials Management agrees with the finding and has immediately implemented new procedures to memorialize the data used to compile and report the UDS report. This included adding all new acquired clinics to the Organization’s Electronic Health Record System.

Department of Health and Human Services Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Special Tests and Provisions Material Weakness in Internal Control Over Compliance and Noncompliance Criteria Health centers must prepare and apply a sliding fee discount schedule (sliding fee discounts) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. The sliding fee discount is based on an individual’s or family’s income in relation to the Federal Poverty Guideline (FPG). In order to support a patient’s eligibility to receive a sliding fee discount, the health center is required to obtain certain documentation from the patient and/or family to support the patient’s or family’s income in relation to the FPG. Condition The Organization failed to obtain the required income verification from three patients; however, these patients were given the sliding fee discount. Cause Internal controls in place did not ensure that the sliding fee discount was not given until all income verification was obtained. Or in cases where the sliding fee discount was granted pending income verification, the income verification was not completed resulting in a sliding fee discount being given without adequate support. Effect The lack of adequate policies governing obtaining the income verification documentation resulted in a sliding fee discount being given without the proper support. In addition, there was not adequate follow up to ensure the income verification was completed for those individuals given the sliding fee discount pending income verification. Questioned Costs Projected to be $25,387. Context A sample size of 65 with a total sample amount of $7,595 was tested. The number of patients who received the sliding fee was 5,512 with a total value or $625,943. Of the 65 tested, four selections, which totaled $556, were given the sliding fee discount when appropriate eligibility documentation was not obtianed. Repeat Finding From Prior Year No Recommendation We recommend that the Organization enhance control policies to obtain the required income verification at the time the sliding fee disounts is granted and to enhance the internal control policies regarding follow up with patients for missing or incomplete income verifications. Views of Responsible Officials Management agrees with the finding.